Abstract
Qi, in traditional Chinese medicine, is envisaged as an energy flowing throughout the body. Any loss of Qi, or obstruction of its circulation, is considered to give rise to grave consequences. Qigong (‘exercise of vital energy’), a method of ‘building vitality and warding off evils’, is regarded as a gem of traditional Chinese medicine [1], and currently enjoys a vogue both on and off mainland China because of its health value [2]. In mainland China, it is said that there is now a ‘Qigong craze’ (Qigong re) [3, [4], [5]]. It has been estimated that not less than 5% of people in China practise Qigong [3] and that 5% of these practitioners develop psychiatric sequelae [6]. Qigong-induced mental disorders have been reported in China [6, [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38]], Hong Kong [39] and in a Chinese immigrant in America [40]. Such a diagnosis is included in the Revised Second Edition of the Chinese Classification of Mental Disorders (CCMD-2-R) [41] and the diagnosis of ‘Qigong psychotic reaction’ is included in the DSM-IVglossary [42]. This article overviews and comments on the relevant literature, as well as critically appraises the passages on Qigong-induced mental disorders and examines if such a causal relationship exists.
Overview of Qigong in ancient and contemporary China
According to Chinese records, Qi-related exercise was evident before the Shang Dynasty (16th–11th centuries BC) [2] and hence has a history of more than 3000 years. Qigong was variably termed daoyin (directing extremities), tuna (exhalation and inhalation) and lianqi (training of vital energy) in ancient China [43].
Qigong-like exercises were accepted by Chinese people in all walks of life, although those living in the imperial court in ancient times were the first to practise them [2]. The Yellow Emperor's Classic of Internal Medicine, written in the fourth century BC, systematically expounded the principles, training methods and effects of practising Qi-related exercises [45, [46], [47]]. It devoted many chapters to detailing the origin, application and theory of such exercises. These include ridding the mind of worries, controlling and concentrating thoughts, breathing exercises and muscle toning.
Zhang Zhong Jing, a renowned physician of the later Han dynasty (BC 206–AD 25), argued, in his Synopsis of the Golden Cabinet, for treating diseases by daoyin (which requires the person to imagine water flowing down the body) and massage: ‘As soon as the limbs feel heavy and sluggish, resort to such treatments as daoyin,tuna, acupuncture and massage by rubbing with ointment so as to allow the orifices to close up’ [47]. Cao Yuanfang of the Sui dynasty (AD 589–618) recorded in his Treatise on the Etiology and Symptomatology of Diseases (published in 610) a great variety of daoyin activities [43, [48]]. In Documents of Yimen, Sun Simiao (AD 581–682) of the Tang dynasty composed a ‘Song of Hygiene’ that detailed the benefits of breathing exercises [43, [49]]. Zhu Danxi (AD 1281–1358), of the Yuan dynasty, suggested ‘seeking quietness by getting rid of desires’ as the theoretical basis for quiet breathing exercises [43].
Traditional medicine was banned in the first half of this century in mainland China, in the rush to modernisation and emulation of the West [22]. After Mao Zedong came to power in the 1940s he recognised the enormous value of traditional knowledge, and instructed officials to research ‘The Storehouses of Treasures’. Although various techniques of cultivating Qi have been previously described, the term Qigong was first used in 1956 by Liu Gui Zhen from Hebei province [50]. The ‘gong’ of Qigong, in the sense of ‘practice’, resonates with its meaning in the phrases gongdi (foundation), gongli (physical strength) and gongfu (or kungfu, literally meaning ‘power and capability’) [1]. In the early 1950s, research into Qigong techniques was started. However, during the 10-year Cultural Revolution from 1966 to 1976, the Chinese government suppressed all activities and endeavours connected with ancient customs. The open practice of Qigong often led to public harassment and possibly even death at the hands of teenaged Maoist Red Guards [25].
After the Cultural Revolution, Qigong practice emerged again. However, critics attacked it as being based on activities and beliefs contrary to governmental policies concerning religious practice and superstition [25]. To resolve the question, the government has, from the late 1970s onward, funded studies to evaluate the essence of Qigong. In 1986, the China Research Society for Qigong Science was founded [51]. In ‘The First World Conference for Academic Exchange of Medical Qigong’ held in Beijing in 1987, there were 128 international presenters who gave papers ranging from scientific and medical research to comparisons with Buddhist and Yoga higher states of consciousness [22]. Qigong has thus survived the vicissitudes of Chinese history and by 1987 it was being practised by at least 20 million Chinese [52].
Qigong has also gained international recognition. In the late 1980s and early 1990s, China hosted several international conferences for the exchange of information on Qigong science [21]. For instance, in 1990, ‘The First International Congress of Qigong’ took place in Berkeley, California, while the 1990s were named ‘The Qigong Decade’. International symposia on Qigong have been held in Prague, Morocco and Toronto since 1973 [43]. In 1975, the Marsh European University in Switzerland made a comprehensive study of breathing exercises from physiological, biochemical and psychological standpoints [43]. Tai Ji Quan (traditional Chinese shadow boxing) is now the most popular Qigong style in the world, even though it was closely shrouded in secrecy until the beginning of this century.
The benefits of Qigong practice
Through exercise of the body, breath and heart, Qigong is believed to cultivate and strengthen a person'szhenqi (genuine energy or body resistance). The main techniques of Qigong can be divided into neigong (internal exercise) and waigong (external exercise). Neigong, practised mainly in a quiescent state, is characterised by concentrating attention on dantian (the elixir field) in concert with inhalation, exhalation and holding of breath in order to stimulate Qi and blood, and to strengthen the constitution. Extroverted individuals and those with unstable moods have been found to have difficulties practising Neigong [53]. Wa i g o n g, practised mainly with mobile exercises, are characterised by ‘external mobility and internal quiescence, seeking quiescence within mobility’ [1]. Examples of waigong include Tai Ji Quan(traditional Chinese shadow boxing) and Wu Qin Xi(Frolic of the Five Animals).
Whether with motion or without, the key point in Qigong is thought to be regulation of the mind, which means to remove all thoughts and focus on a certain region of the body, the elixir field [2]. This brings the experienced Qigong practitioner into a state of warmth, lightness and tranquillity. As the body relaxes, the mind concentrates on the elixir field and all other thoughts are erased, while respiration becomes deeper and gradually decreases in frequency. When the respiration rate is decreased to four or five times per minute, the subject falls into the socalled ‘Qigong state’ [7]. Great changes in respiration and energy metabolism may be indicative of the results of long-term intensive practice of meditation but not necessarily representative of the changes in the novice practitioner [54].
The Chinese physicians describe two ways to cure diseases using Qigong [1]. The first is for a Qigong master to send external Qi to patients; however, this kind of Qigong master is very rare. Also, curing disease by external Qi greatly consumes a Qigong m a s t e r's strength, thereby preventing him from meeting the needs of a great many people. The second is a self-treatment method: a patient can practise Qigong alone to improve physical functions, strengthen physique and rid the body of diseases. Qigong has been used to treat patients with the following psychosomatic and psychiatric conditions: hypertension, malnutrition, coronary heart disease, peptic ulcer, asthma, diabetes, sciatica, arthritis, headaches, migraine, myalgic encephalomyelitis, neurasthenia, anxiety disorder, phobic states and obsessive–compulsive disorder [19, [20], [26]].
Scientific studies have used variable approaches. Wang [55] administered a standard psychological test to 35 subjects before and after Qigong practice and found that, after practising Qigong, areas of improvement include memory, attention span, thinking process, stability of emotions, mood, self-control, temper, willpower and speed of action. Wang [56] examined the relationship between the length of time his subjects had practised Qigong and the extent of improvement in psychiatric symptoms. The group with more experience (2 years or more) had significantly lower scores in the following areas: obsessive–compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, fears and neuroticism. A limitation of these studies is that, although the subjects have improved, the factors responsible for change have not been isolated.
Changes in electroencephalograms during Qigong practice have been documented. After 1 or 2 min of practice, the amplitude of alpha waves increases, first in the occipital lobe, and subsequently in the frontal lobe and with decreased frequency [7]. T h e s e changes are generally maintained throughout Qigong practice. During Qigong, theta waves also increase, although generally not to the same degree as alpha [21]. The degree of coherence between different portions of the brain also increases during Qigong, in proportion to the expertise of the practitioner [21]. The predominance of alpha waves indicates that Qigong induces a relaxed and focused state of mind, while the simultaneous presence of theta waves means that the practitioner is becoming aware of deeper levels of consciousness [21]. The asymmetrical alpha waves between the two hemispheres have also been observed to become symmetrical [7]. Enhanced coherence may be a key finding. According to Orme-Johnson [57], it represents a ‘low-noise’ state in the brain; that is to say, it reflects the mind–brain system becoming quiet, which in turn allows meditative altered states of consciousness to emerge. Xie [7] argued that ‘Qigong state’ is not a dormant one, and with improved synchronisation, Qigong may improve physiological processes of the brain cells. After practice, one is usually in high spirits, able to think quickly and clearly, and has sharpened sight and hearing.
Qigong deviations: The traditional Chinese physician's viewpoint
Qigong, if practised inappropriately, is held to induce abnormal psychosomatic responses, and even mental disorders [7]. These abnormal responses, known as Qigong deviations or aberrations in traditional Chinese medicine, have distinctive Qi-related manifestations. Qigong-induced health disturbances (pian cha) are believed to arise from the inappropriate application of Qigong, incorrect regulation of the mind to reach the ‘tranquil’ state or to control respiration, and/or the inability to ‘terminate Qigong’ (shou gong) [3]. It is recommended that at the end of every practice one should finish with shou gong to bring all the Qi back to the elixir field and store it there; this procedure will also make the practitioner calm and relaxed [27]. It is believed that every Qigong style has its own special training methods and objectives and that if the style is not compatible with the individual's constitution and physique, Qigong deviations may ensue [26]. The traditional Chinese physicians classify Qigong deviations into the following categories:
Sensory disturbances
In the mildest form of Qigong deviations, the symptoms are due to Qi scurrying in abnormal directions in the body, giving rise to a special sensation of Qi rushing to the head, distension at the elixir field, distress in the chest and feeling of suffocation [7]. Associated symptoms include nervousness, insomnia, disturbed sleep, frequent dreams, tachycardia, breathlessness, dry mouth, headaches and giddiness. A result of intense concentration, anxiety and unnatural breathing during the practice, this is thought to be corrected by relaxing the body and mind. Ancient medical literature describes the sensation experienced by Qigong experts as that of vital energy sinking into the lower elixir field located in the abdomen during deep breathing. In fact, the sensation comes from a natural protrusion of the abdominal wall as a result of increased pressure caused by the movement of the diaphragm during respiration [43]. Some individuals may also complain of Qi flowing in their bodies, of their Qi affecting others, and of perception of Qi sent out by others, especially if the exercise is conducted in a group. All of these symptoms may be accompanied by numbness, aches and parasthesias. Many individuals in such states are diagnosed by psychiatrists to suffer from a neurotic disorder [8, [18]].
Motor disturbances
These may occur in isolation or in conjunction with sensory disturbances. During exercise, spasmodic twitching of the head and torso may occur [58]. Shaking of the head and torso is thought to be due to Qi sinking into the lower elixir field, which culminates in abnormal pressure. Zhao [28] detailed the unusual experiences reported by 100 Qigong practitioners: spasmodic twitching of the muscles (40 people), cramps (1), severe tremors (4), spontaneous movements (7), warm sensations over the body (66), coldness over the extremities (18), itch (15), numbness (2), relaxation (21), tension (2), sensation of Qi circulating within the body (28), floating sensations (33), heavy sensations (6), sensation of body disappearing (25), perception of the body becoming bigger (11) and becoming smaller (7).
The motor manifestations of tremors, odd movements of the limbs and uncontrolled motor activity may persist for hours [6]. However, the Chinese physicians explained that these could be due to Qi clearing the blockades in the meridians and do not necessarily indicate errors of practice [58]. Spontaneous movements are deemed part of the Qigong legacy [22] and are called ‘moving meditation’; the Greek also had a word for them: kinesi atrics or ‘healing through movement’ [59].
Psychic disturbances
Alterations in consciousness (hun mi)
Characterised by mental confusion and a dazed feeling, these disturbances may be accompanied by labile affect, tremors and involuntary movements, paucity of speech, mutism, aphonia, weakness of limbs and loss of vision [7]. Consciousness is altered during the episode but may be difficult to test, and patients are amnesic for the episode. People with this condition, who are usually suggestible females, may even develop such states after their first lesson in Qigong [18]. Psychosocial stressors among these individuals have been reported [8, [18]].
Spirit possession
The common symptoms are altered states of consciousness, hallucinations and identity disturbances, usually of being possessed by an alternative identity such as an animal spirit, a deity or the spirit of the Qigong master [7]. These states may occur abruptly but are usually short-lasting and the patients do not have any psychotic features upon resumption of their normal states of consciousness. Possession by animal spirits is understandable as some techniques of Qigong imitate the movements of birds and beasts. For instance, Frolic of the Five Animals, a Qigong style created by the master of medicine, Hua Tuo, of the Three Kingdoms (AD 220–280), imitates the movements of five kinds of bird and beast (the bear, tiger, monkey, deer and crane) while retaining the characteristics of the human body [1].
Distracting thoughts
Some Qigong practitioners may have no ruminations generally, but when they are exercising, they may ponder over many questions and experience difficulty controlling their thinking [7]. This is thought to prevent the arrival of quietude, or the state of nothingness, which is essentially ‘clarity’. Tse [27] believes that the main reason people have difficulty concentrating is that they want to settle the body down too fast. The Qigong master would suggest that this condition could be overcome by replacing all distracting thoughts with one thought, such as concentrating on the word ‘relaxation’ or ‘quietness’ [43]. If the practitioner finds himself distracted during practice, it is best to terminate the exercise and find another time or place to continue [27].
Mental derangement
The psychotic patient may visualise apparitions, experience auditory hallucinations in the form of voices of supernatural beings teaching him Qigong [60] and may develop delusions that he was contacting beings from another dimension [7]. Some manifest the delusion of being a Qigong instructor with supernormal power and the ability to receive messages without using the ordinary five senses. It is also believed that when acupuncture points on the upper part of the head, which are called ‘Sky-eye’ and ‘Sky-door’, have opened, one is capable of receiving messages from outside and reading people's minds even when they are far away. Other clinical features include incoherent speech, excitement, depression, fright, bewilderment, catatonia, or paranoid symptoms [58]. These severe reactions are collectively known as zou (‘run’) huo (‘fire’) ru (‘enter’)mo (‘devil’), which means that the flow of Qi deviates from the conduits, creates havoc and culminates in the intrusion of a devil into the person (metaphorically, referring to the emergence of psychotic symptoms) [3]. Zou huo ru mo describes delusional thinking that results from incorrect and excessive training.
Qigong-induced mental disorders: The psychiatrist's viewpoint
The Revised Second Edition of the Chinese Classification of Mental Disorders (CCMD-2-R), widely used by psychiatrists in China, classifies mental disorders based on both symptomatology and aetiology [35]. The Chinese psychiatrists seek either to diagnose in accordance with ICD-10 or to sustain a nosology with Chinese cultural characteristics. One specific diagnostic category of mental disorders, mental disorders closely related to the culture, has been created in the CCMD-2-R, and is regarded as having culturally specific conditions in China [41, [61]].
Profiles and clinical features of patients with Qigong-induced mental disorders
Most Qigong lessons are conducted under the supervision of an instructor in a group setting, although an individual may also choose to practise alone while listening to tapes or reading some manuals or magazines [18]. A survey of 207 cases of Qigong-induced mental disorders carried out by Shanghai Mental Hygiene Centre revealed that 76% lacked proper guidance and practised Qigong on their own [30]. Suggestion and self-suggestion are regarded as an important mechanism in the onset of Qigong-related disorders [61, [62]]. While using the mind to help Qi circulate (yi yi yin Qi), in the altered states, the practitioner may experience changes in his emotions, perceptions and cognitions. A proportion of people may interpret these changes as indicators of extraordinary human abilities or paranormal experiences. Some welcome and strive for these experiences but are not able to place them in a proper cognitive setting. A person who believes in the miraculous powers of Qigong may accept these influences as indicators of potential powers and may go on to display his imaginary powers [58].
It is believed that when Qigong is practised to a highly quiescence-entering state, one could see without eyes and listen without ears [58]. It is as if the meditating person tries to disconnect his focus of attention from the present central and shared world, while allowing access to stimuli from the fringe of his attention [63]. Hallucinations have been reported under such situations. Like possession-trance, it is a state of the mind that can be trained. The Qigong master has a high level of self-control and is able to shift in or out of the altered consciousness at will [21]. If the misguided practitioner is too eager for results, and when he fails to achieve the ‘Qigong state’, he becomes anxious and impatient.
For Qigong-induced mental disorders to qualify as a separate entity, they must have a different course and outcome from other mental conditions. There are insufficient data available in the literature on the long-term course to be expected for Qigong-induced mental disorders. He [4] briefly indicated that most cases recovered after 1–2 months, while a few had a protracted course and recovered after 1–2 years. However, the author did not furnish details on their demographic profiles, social support systems, symptomatologies and the indices of recovery used. Wu [16] studied 76 patients with Qigong-induced mental disorders and revealed that they differed from schizophrenia sufferers by their age of onset, aetiology, symptomatology, treatment response as well as prognosis. However, as Qigong-induced mental disorders comprise a mixed group of conditions, of more importance is the identification of specific subgroups and the determination of parameters associated with response to treatment.
Treatment and prevention
When the individual experiences a deviation caused by incorrect practice of Qigong, he is advised to consult with a Qigong instructor or a Qigong doctor at a Qigong Hospital. As most cases are short-lasting, they never come to medical attention [3]. It is believed that since most beginners do not generate a significant amount of Qi, these phenomena may be harmless. However, if the practitioner ignores these warning signs and persists in training incorrectly, harm to the body may eventually result [26]. Indigenously devised forms of Qigong correction therapy (jiu pian) are available [10]. Most symptoms may be corrected by relaxing mental concentration and breathing naturally; some may require the institution of herbs and acupuncture [35]. These reactions are also treated by psychiatrists using a combination of medications (anxiolytics, antidepressants and neuroleptics) and psychological interventions [8]. Those who need to consult psychiatrists probably suffer from severe forms of Qigong-related complications [3].
The traditional Chinese physicians conceptualise Qigong deviations as usually due to incorrect regulation of the mind to reach the ‘tranquil’ state or to control respiration. Especially vulnerable are individuals who become overly involved in the practice or who practise intensively. Proper coaching is hence mandatory to practise Qigong safely and a typical session should not exceed 3 h [8]. People with intermittent psychotic states are often perplexed and embarrassed about what has happened to them while psychotic. They also fear further continuing bouts, with a descent into insanity. In order not to experience psychotic reactions again, recovered patients may readily cease practising or change to a more gentle form of Qigong [3].
Some Qigong masters profess to have highly developed psychic and paranormal abilities. This has become a source of intense enquiry in China lately and there have been investigations of extraordinary abilities by these people, some of whom have been found guilty of fraudulently misrepresenting Qigong for their own personal financial advantage and have been jailed [22]. Qigong can be passed on in small private groups, so it is not altogether proving easy for the authorities to supervise or control [22].
To cultivate and develop good practice, the learner of Qigong is advised to seek good instruction, understand the practices correctly, master the basic skills and proceed gradually, step by step. Most importantly, it is recommended that he leads a balanced life with moderation and does not neglect the joys of everyday life. The practitioner is advised not to approach Qigong rigidly or militaristically [21]. Mastering Qigong requires dedication and perseverance. The negative reactions can be avoided by following the instructions carefully and by practising with moderation, patience and intuition [21]. The Qigong master maintains that any discipline can be harmful if it preoccupies the mind or is practised incorrectly [59].
Discussion
Many of the studies on Qigong and mental health have been flawed by failing to follow the scientific method with sufficient rigor. Some, for instance, have no control subjects or have used sample sizes too small to be meaningful [21], while many are based on qualitative data, often idiosyncratically collected and described. Careful and replicable research with strict methodology has largely been lacking in this area. The process of learning Qigong exposes the individual to a variety of pressures which create difficulties for interpreting research results. There are social pressures upon the individual to experience and report benefits. There is also the problem that some experimenters may themselves be Qigong teachers or practitioners and so their motivations may have some effect on the outcome of the experiment [54].
To understand ‘Qigong craze’, one needs to appreciate the sociopolitical environment that China faced in the early 1980s, when revival of interest in Qigong coincided with the period when Chinese people were recovering from the destruction caused by the Cultural Revolution. With awareness of health issues, there is a demand for better healing systems and as Qigong is the most valuable part of China's medical legacy, this art spreads rapidly and the country is gripped with ‘Qigong fever’. Another attractive feature of Qigong is its low cost, since it requires neither exercise equipment nor invasive or costly medical procedures. When millions practise Qigong, casualties are not surprising.
The concept of Qi, however, is not exclusively Chinese, for the Indian prana, the Greek pneuma, and the Hebrew ruakh all have much in common with it. It would be relevant to examine if phenomena similar to Qigong deviations occur in these cultures. Although meditation practices have appeared across cultures, mental disorders following meditation are rarely encountered in other cultures. As such, Qigong-induced mental disorders would qualify as a culturally specific condition among Chinese. Cross-cultural studies are required to examine the predisposition of Chinese to develop psychiatric complications. Carrington [64] refers to the dangers of meditation, which he believes, stem from over-meditation, a belief supported by the finding that over-meditation (e.g. 3-h sessions) can cause serious emotional disturbance and hallucinations [54].
The entity ‘Qigong-induced mental disorders’ actually includes a mixed group of neurotic and psychotic disorders [8]. A consensus on the classification of Qigong-induced mental disorders is lacking, and CCMD-2-R has not addressed this issue specifically. In the late 1970s, Cohen coined the diagnostic terms ‘Qigong psychosis’ and ‘Qigong psychotic reaction’ as translations for the Chinese expression zou huo ru mo, ‘fire (the Qi) wild, devils enter’ [21]. It was only in 1994 that the term ‘Qigong psychotic reaction’ was included in the DSM-IV Glossary of Culture-Bound Syndromes [42]. DSM-IV fails to indicate that neurotic reactions can also occur following Qigong, a fact highlighted in the Chinese publications. Many of the fragments translated in this short paper have not appeared before in English and it is hoped that this paper would help bridge the gap between Chinese and American psychiatry.
It is important to realise that the inducer role of Qigong has not been convincingly proven. If it were not for the fact that these patients had practised Qigong, the clinical phenomena are very similar to anxiety disorder, conversion disorder, dissociative disorder, obsessional disorder, schizophrenia and other psychotic conditions, and are therefore quite protean. Zhai [18] distinguishes between two types of psychosis following Qigong practice: schizophrenia-like psychosis and relapse of schizophrenia. The former occurs in patients with first-episode psychosis, has a brief duration, and the contents of the hallucinations and delusions are closely connected with Qigong, whereas the latter occurs in individuals with a past history of schizophrenia, has a longer duration, and the contents of hallucinations and delusions are unrelated to Qigong. Huang [31] emphasises that Qigong-induced psychosis differs from schizophrenia in that insight is usually maintained in the former, but this finding has yet to be validated by future studies and the symptoms in Qigong-induced psychosis may be misinterpreted or embellished by the patient and behavioural disturbances may hence result. The Chinese psychiatrists maintained that the temporal sequence of events linking the abnormal behaviour to Qigong would verify that the consequences are indeed consistent with what is known about the adverse effects of Qigong. However, the ties between Qigong and mental disorders are essentially manifold and a causal relationship is difficult to establish. In part, this may occur because of the tendency for physically and psychologically ill subjects to practise Qigong. A person, for instance, may try to heal himself through the use of Qigong during the early stages of a psychotic disorder. Impaired judgement when ill may explain the propensity for psychiatric patients to practise Qigong in an unorthodox fashion, more intensely or over prolonged periods. Many so-called ‘Qigong-induced psychoses’ could be seen as ‘Qigong-precipitated psychoses’, where practice of Qigong acts as a stressor in vulnerable individuals. A small proportion of any case sample of people who practised Qigong and studied over time will probably have a mental disorder because of the onset of the disorder during this time.
The aetiological role of Qigong in dissociative disorders merits some consideration. Trance is essentially a narrowed focus of attention such that what is outside of attention is lost to consciousness. It allows persons to transcend the subjective limitations of time and space and permits direct personal experience with supernatural beings. Altered states of consciousness involve imagery, imagination and acceptance of phenomenal experiences suggested by an authority. Prior and early involvement in Qigong, an altered state of consciousness, may encourage the initial use of dissociation as a defence, and pave the way for dissociative behaviours. Recent exposure to Qigong may heighten the susceptibility of an already vulnerable person. Practice and experience in Qigong make for relative ease in negotiating the transition from the normal to the ‘Qigong state’ when faced with intolerable life situations.
Many novice practitioners do not appreciate the usefulness and limitations of Qigong and base their knowledge primarily on popular press reports and movies, which often portray Qigong as a ‘miracle producing’ exercise. Some also believe in extrasensory perception (ESP, telepathy, sixth sense) and clairvoyance, which refers to the ability to see what will happen in the future. Subscriptions to such beliefs reflect a willingness to accept ideas that are not supported by scientific facts. Believers are less adept at critical thinking and logical reasoning and are more likely to attribute life's events to unseen and mysterious uncontrollable forces [61]. As Reed [65] puts it: ‘Each set of beliefs presupposes the necessity of suspending objective standards of determination. And each not only allows for, but requires that experiences of the sort described should occur. To those who believe, such experiences are not only accepted, they are expected to occur’. Suggestibility is considered by Pick [66] to be dependent on alteration in consciousness, weakened judgement and the interplay of fantasy. That Qigong demonstrations are mostly carried out in a crowd situation is relevant here, for a zealous group can arouse emotions and then prime the individuals to accept unaccustomed explanations and adopt new attitudes and beliefs.
A common thread running through the various accounts of Qigong-induced mental disorders is the changing assumptions and concepts of mental disorders in China. The content of hallucinations and delusions will always be based on a person's cultural schema. During the 10-year Cultural Revolution of the 1970s, many Chinese patients with schizophrenia manifested delusions of persecution [50]. Revival of interest in Qigong started in the early 1980s, and since then, academic interest in the mental disorders it may plausibly induce has been growing. The accounts on Qigong-induced mental disorders highlight the influence of traditional medicine in China, the pathoplastic effects of culture and its implications on psychiatric diagnosis and treatment. In the assessment of cases presenting with Qigong-precipitated psychiatric sequelae, it is important to study the conditions under which they occur and their location in space, time and culture.
Footnotes
Acknowledgements
The author is grateful to Dr Leslie Lim, Associate Professor Chee Kuan Tsee and Professor Gordon Parker for valuable comments on earlier drafts.